Background

As a nurse practitioner working in primary care, Katie S. Wingate, DNP, AGNP-C, was
well aware of the discontinuity of care her patients experienced when they were hospitalized.
“We are the last independently owned primary care office in town,” she
said. “When our patients go to the hospitals, we weren't in the loop at all.
We were really frustrated not even knowing if someone was in the hospital. When they
come in for follow-up, we don't know what happened.”

In addition to causing frustrations, these disconnects were likely increasing patients'
risk of readmission, Dr. Wingate explained during a presentation at the American Association
of Nurse Practitioners' annual conference, held in Philadelphia in June. “I
did a brief literature review. I was really hoping that there would be some simple
answer. That was naïve. I quickly found out that there is no simple answer.”

In her research, Dr. Wingate did find a multicomponent intervention that offered potential
answers, the Transitional Care Model, and she modeled her efforts on it.

How it works

From June to October 2015, Dr. Wingate intervened every time one of her practice's
community-dwelling elderly (65 years or older) patients was hospitalized with chronic
obstructive pulmonary disease, heart failure, acute myocardial infarction, pneumonia,
diabetes, or hypertension. The local hospital provided her with limited access to
its electronic health record (EHR) system so that she would be notified.

“It would pop up: ‘John Doe is admitted.’ So I'd schedule a time
to go over there and meet with him,” she said. The meeting was more of a check-in
than a clinical visit, she explained: “How are you doing? What do you need?
What questions do you have? Let me review your chart and go over this with you.”
She'd also speak with the treating hospitalist or other inpatient care team member
if possible.

After Dr. Wingate was notified through the EHR that patients were discharged, she
would call them within two days to review medications and make a follow-up appointment.
She also saw patients for their follow-up appointments, which occurred within 14 days
of discharge.

“Most of the time it was more like a week or less. That's when we reviewed
the discharge summary and made sure all their medications were correct. If they needed
any labs or diagnostic imaging or referrals, that got taken care of,” she said.
Patients also received a patient-centered care plan, a booklet with information about
their health conditions, medications, and red flags to seek care.

Results

Thirty-six eligible patients from the practice were admitted while Dr. Wingate was
conducting the project, but 20 of them were excluded from the project for various
reasons, including that they were discharged before she could get to the hospital
or that they declined to participate.

That left 16 patients she visited, 15 of whom she talked to on the phone and 11 of
whom came to the follow-up office visit. One of the 11 was readmitted to the hospital
and died there within 30 days of the initial discharge. The other 10 were not readmitted,
for an overall readmission rate of 6.25%, which compares well with national and local
averages.

“Of course, our findings were not statistically significant, but clinically
significant? Maybe,” said Dr. Wingate. “If nothing else, the patients
liked it and it was helpful to them.” One medication error was caught, and
patients rated their satisfaction with the intervention at 4.9 out of 5.

Dr. Wingate's clinician satisfaction also increased. “It was so much easier
to do the follow-up visit in the office, because I had been there throughout the process.
I knew what had happened. I had the discharge summary that I wanted. It was just so
much easier and less stressful, and I actually got to spend time with the patient
and wasn't screaming and pulling my hair out,” said Dr. Wingate.

Challenges and next steps

Once the challenge of getting the necessary information from the hospital was overcome,
the biggest hurdles were patient buy-in and clinician time, Dr. Wingate said. She
spent an average of 25 minutes on the hospital visit, seven minutes on the phone,
and 23 minutes on the follow-up visit. The hospital visit wasn't reimbursed, but the
intervention did allow the practice to bill transitional care management codes, which
increased payment for follow-up office visits by $92 per patient in the project, compared
to a 99214 visit.

A shortage of time has prevented Dr. Wingate from continuing the project as a regular
part of practice, despite her belief and the evidence that it did improve care. “We've
lost a provider. We're swamped. We're going to try to do this when we get a little
bit back on our feet,” she said.

Dr. Wingate noted that the project was well received by inpatient clinicians, but
it didn't reduce the discontinuity between settings over the long term. “Did
anyone call me in the office? No,” she said. “If I continue . . . I
hope that will improve.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.